A nurse is planning to complete dressing changes for an adolescent who has multiple burn injuries. Which of the following interventions addresses the greatest risk to the client?
Apply tepid water to the old dressings before removal.
Check the wound sites for manifestations of infection.
Perform passive range-of-motion exercises during the dressing change.
Adjust the room temperature to 33°C (91.4°F).
The Correct Answer is B
Choice A reason: Applying tepid water to the old dressings can help with their removal and may reduce discomfort, but it does not address the greatest risk to the client, which is infection.
Choice B reason: Checking the wound sites for manifestations of infection is crucial as burn injuries compromise the skin's protective barrier, making the client highly susceptible to infections. Infections can lead to further complications and delay healing.
Choice C reason: Performing passive range-of-motion exercises is important for maintaining joint mobility and preventing contractures in burn patients, but it is not the primary intervention for addressing the greatest risk of infection.
Choice D reason: Adjusting the room temperature to 33°C (91.4°F) can create a more comfortable environment for the burn patient and prevent hypothermia, but it is not directly related to the prevention of infection, which is the greatest risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Irregular bluish pigmentation on the sacral area could indicate a Mongolian spot, which is common and usually harmless, but it could also suggest other conditions that may require further evaluation. Reporting this finding is important for proper assessment and documentation.
Choice B reason: Slow, rhythmic movements of the lower extremities are normal in newborns and are known as primitive reflexes. These movements are expected and do not typically require reporting unless they are absent or abnormal.
Choice C reason: An anterior fontanel size of 3 cm (1.2 in) is within the normal range for a newborn. The fontanel should be soft and flat, and changes in size or tension should be monitored over time.
Choice D reason: Enlarged breasts in newborns are also common due to maternal hormones and usually resolve without intervention. It is not a finding that typically requires immediate reporting unless there is redness, swelling, or discharge.
Correct Answer is C
Explanation
Choice A reason: Providing frequent range of motion to the neck and shoulders is not recommended for an infant with bacterial meningitis, as it could cause discomfort or pain due to the inflammation of the meninges.
Choice B reason: Keeping the television on to provide background noise is not advisable, as infants with meningitis may be sensitive to noise, and it could potentially increase their discomfort or agitation.
Choice C reason: Padding the siderails of the crib is important to ensure the safety of the infant. It helps to prevent injury if the infant has seizures, which can be a complication of meningitis.
Choice D reason: Placing the infant in a semi-private room is not a specific intervention for the care of an infant with bacterial meningitis. It is more important to focus on interventions that address the infant's immediate health needs.
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